PLACE LABEL HERE
INFORMED CONSENT FOR
ARTERIOVENOUS DIALYSIS SHUNTOGRAM
(This form is designed to comply with the Georgia Informed Consent Law O.C.G.A. 31-9-6.1)
PATIENT NAME: _____________________________________
DATE: ________________________
TIME: ________________________
The diagnosis or clinical history requiring this procedure is: dialysis graft narrowing or blockage.___________________
_________________________________________________________________________________________________
The nature of the procedure is: Arteriovenous Dialysis Shuntogram – 1.) Evaluate the graft by injecting x-ray_____
contrast (dye) into the arm fistula and take x-ray images. 2.) Angioplasty – dilate any narrowing if needed with a balloon
or stent, and 3.) Anticoagulation Therapy – infusion of blood thinners or clot busting agent. 4.) Use of mechanical_____
thrombectomy device.________________________________________________________________________________
The purpose of this procedure is: to diagnose and treat narrowing of dialysis graft.______________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
THIS PROCEDURE INVOLVES THE MATERIAL RISK OF INFECTION, ALLERGIC REACTION, SEVERE LOSS OF
BLOOD, LOSS OR LOSS OF FUNCTION OF ANY LIMB OR ORGAN, PARALYSIS, PARAPLEGIA OR
QUADRIPLEGIA, DISFIGURING SCAR, BRAIN DAMAGE, CARDIAC ARREST OR DEATH.
ADDITIONAL RISKS: In addition to the material risks listed above, there may be other potential risks involved in this
procedure including, but not limited, to the following: bleeding, infection, dye allergy, or injury to the fistulas which could
require surgery to repair.______________________________________________________________________________
__________________________________________________________________________________________________
The likelihood of success of this procedure is:
[ x ] good
[ ] fair
[ ] poor
THE PRACTICAL ALTERNATIVES TO THIS PROCEDURE ARE: no intervention or surgical repair._____________________
__________________________________________________________________________________________________
If I choose not to have the above procedure, my prognosis (future medical condition) is: uncertain._________________
__________________________________________________________________________________________________
I understand that during the course of the procedure described above, it may be necessary or appropriate to perform
additional procedures which are unforeseen or not known to be needed at the time consent is given. I consent to and
authorize the persons described herein to make the decisions concerning such procedures. I also consent to and
authorize the performance of such additional procedures as they deem necessary or appropriate.
I consent to diagnostic studies, tests, x-ray examinations and any other treatment or courses of treatment relating to the
diagnosis or procedures described herein.
*2-13005*
FORM 2-13005 REV. 03/2006
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I consent to the use of IV sedation and/or anesthesia and understand the risks are those associated with the procedure
itself as listed above. The options have also been explained to me.
I consent to the use of blood and blood products as deemed necessary. The risks of exposure to AIDs, hepatitis or other
infectious diseases as well as the need for and available alternatives have been explained to me.
I consent that any tissues, specimens, organs or limbs removed from my body in the course of any procedure may be
tested or retained for scientific or teaching purposes and then disposed of within the discretion of the physician, facility or
other health care provider.
I understand that the physician, medical personnel and other assistants will rely on statements about the patient, the
patient’s medical history, and other information in determining whether to perform the procedure or the course of
treatment for the patient’s condition and in recommending the procedure which has been explained.
I understand that the practice of medicine is not an exact science and that NO GUARANTEES OR ASSURANCES HAVE
BEEN MADE TO ME concerning the results of this procedure.
BY SIGNING THIS FORM, I ACKNOWLEDGE THAT I HAVE READ OR HAD THIS FORM READ AND/OR
EXPLAINED TO ME IN GENERAL TERMS, THAT I FULLY UNDERSTAND ITS CONTENTS, THAT I HAVE BEEN
GIVEN AMPLE OPPORTUNITY TO ASK QUESTIONS AND THAT ANY QUESTIONS HAVE BEEN ANSWERED
SATISFACTORILY. ALL BLANKS OR STATEMENTS REQUIRING COMPLETION WERE FILLED IN AND ALL
STATEMENTS I DO NOT APPROVE OF WERE STRICKEN BEFORE I SIGNED THIS FORM. I ALSO HAVE
RECEIVED ADDITIONAL INFORMATION, INCLUDING, BUT NOT LIMITED TO THE MATERIALS LISTED
BELOW, RELATED TO THE PROCEDURE DESCRIBED HEREIN.
I hereby voluntarily request and consent for Dr.____________________, as my physician, and any other physician(s),
and such associates, assistants or other medical personnel involved in performing such procedure(s), to perform the
procedure(s) described or referred to herein. I further consent to the presence of device or supply manufacturer’s
representatives in the operating room as may be deemed appropriate by my physician.
Additional materials used, if any, during the informed consent process for this procedure include: __________________
__________________________________________________________________________________________________
___________________________________
Signature of Person Giving Consent
___________________________________
Relationship to patient if not the patient
Patient unable to sign because:
Responsible Practitioner’s Statement:
____________________________________________________
I have reviewed the contents of this form, including the risks, benefits and alternatives to the proposed procedure, with
the patient or the patient’s decision-maker, and have provided the patient/decision-maker with an opportunity to ask
questions.
___________________________________
Responsible Practitioner
FORM 2-13005 REV. 03/2006
___________________________________
Date/Time
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